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*For medical professionals only
Status epilepticus (SE) refers to frequent recurrences of consciousness that do not fully recover between successive seizures, or that seizures do not stop
on their own for more than 30 minutes.
Long-term seizures, if not treated in time, can lead to irreversible brain damage due to high fever, circulatory failure or neuronal excitotoxic damage, and the disability rate and mortality rate are very high, so neurologists should be familiar with the diagnosis and treatment
of SE.
The author summarizes the relevant content for your reference
.
Definition of SE SE has been defined as continuous seizure activity lasting more than 30 minutes, or intermittent but repetitive seizure activity lasting more than 30 minutes without regaining
consciousness between seizures.
However, given that solitary seizures rarely last longer than 5 minutes, the definition of SE has been revised
.
SE is now defined as a continuous seizure of more than 5 minutes or two or more discrete seizures during which consciousness is not fully restored
.
In 2015, the International League Against Epilepsy (ILAE) revised the classification
of SE based on seizure symptomatology, etiology, age, and EEG.
In clinical practice, the most commonly used classification is based on seizure symptomatology, which refers to the initial clinical manifestations
of seizure activity.
The two main components of initial presentation are the presence or absence of motor symptoms and the degree of
impaired consciousness.
According to the new classification in 2017, SE is divided into SE with obvious motor symptoms and impaired consciousness [i.
e.
, convulsive SE (CSE)] and SE without obvious motor symptoms, with or without impaired consciousness (i.
e.
, NCSE).
Diagnostic evaluation of SE The diagnostic evaluation of SE should be guided
by clinical presentation.
Common initial investigations include routine laboratory tests, drug toxicology screening, and CSF analysis
in patients with suspected infection or autoimmune causes.
In the acute phase, brain imaging (with or without contrast) by CT is the preferred mode to rule out causes of acute symptoms, such as intracerebral hemorrhage or tumors.
Once the patient is stable, further evaluation
is required.
MRI imaging of SE may resemble stroke, with abnormally high T2 signal and limited diffusion, often involving the cerebral cortex and hippocampus
.
CSE evolves into nonconvulsive seizures (NCS) and NCSE is very common, especially in the first 24 hours
.
Therefore, serial EEG monitoring should be initiated immediately, especially in patients with
persistent altered mental status and a high risk of seizure recurrence.
In critically ill patients with suspected NCS or NCSE, the use of ambulatory EEG can effectively improve the early detection rate of NCS/NCSE and reduce in-hospital mortality
.
The differential diagnosis of partial epileptic state of SE needs to be distinguished from transient ischemic seizure (TIA), TIA can appear episodic hemibody numbness, weakness, etc.
, without consciousness impairment, lasting for several minutes to tens of minutes, easy to be confused with simple partial status seizure
。
TIA is more common in middle-aged and elderly people, often accompanied by hypertension, cerebral arteriosclerosis and other stroke risk factors; Epileptic status should be distinguished from hysteria, migraine, hypoglycemia, and organic encephalopathy, and history and EEG are important differentiators
.
The processing of SE The treatment of SE mainly follows the following 4 principles:
Since most SEs usually occur pre-hospital, as with any medical emergency, it focuses on stabilizing the patient's respiratory and circulatory state
.
This includes keeping the airway open and intubating the airway if there is concern about damage to the airway
.
For patients with reduced oxygen saturation who do not require intubation, oxygen can be given through a nasal cannula or mask, and intravenous access is established
.
In addition, a rapid neurologic evaluation is required to determine the type of SE and underlying cause.
▌ First-line benzodiazepines
are recommended first-line ASM treatments
for CSE and NCSE.
The Neurocritical Care Society and the American Epilepsy Society recommend rapid administration of benzodiazepines within 5 minutes and 5-20 minutes
, respectively.
When intravenous access is available, intravenous lorazepam is the initial agent
of choice.
Lorazepam is administered at a dose of 0.
1 mg/kg, with a maximum rate of 2 mg/min, or a fixed dose of 4 mg, and can be repeated every 3 to 5 minutes if seizures persist
.
When intravenous access cannot be established, midazolam 10 mg intramuscularly is also effective and safe
.
▌ About one-third of patients with second-line
SE do not respond to benzodiazepine therapy, and the risk of seizure recurrence is high
.
Second-line long-acting therapy is essential to prevent seizure recurrence and to treat seizures that may persist, particularly in patients
at high risk of NCSE with persistent mental status changes.
Second-line antiepileptic drugs (ASMs) should be given
intravenously as soon as possible.
Levetiracetam, valproate, fosphenytoin, and lacosamide are the most commonly used drugs
.
Treatment of refractory SE is defined as ineffective
seizure control after adequate doses of first- and second-line ASM.
One third of patients with SE may progress to RSE and respond less than 10%
to the addition of a third ASM agent.
Rapid initiation of intravenous anesthetic drugs (intravenous access) is recommended to shorten the duration of seizure activity and prevent progression to super-refractory SE (SPSE).
These should always be initiated with ambulatory EEG monitoring to begin monitoring response, along with ongoing blood pressure monitoring
.
Complications associated with SE Convulsive SE may cause a wide range of acute and chronic systemic complications
.
▌ Neurological complications
Acute postictal encephalopathy is a common early complication caused by a combination of prolonged seizures and the use of sedative drugs
.
Focal neurologic deficit is another complication, particularly in patients with
focal motor seizures.
This may be due
to focal neuronal necrosis of the neocortex, hippocampus, and basal ganglia due to seizure activity.
Postictal weakness due to seizure activity is usually transient and improves
within minutes to hours.
▌ One third of SE patients with respiratory complications
will have airway damage and respiratory failure
that require intubation.
Changes in respiratory muscle contraction and the use of sedative ASM can lead to airway damage and, in severe cases, respiratory failure
.
However, sustained seizure activity is associated
with a higher risk of intubation compared with ASM alone.
▌ Cardiovascular complications occur in 2/3 of SE patients with cardiovascular complications
, which are associated
with increased mortality.
Electrocardiogram (ECG) changes are most common and can last up to 24 hours
after seizure activity stops.
At initial presentation, more than 80% of patients present with sinus tachycardia, and bradycardia
is rarely present.
Some patients may present with more severe arrhythmias, including atrial fibrillation or flutter, ventricular tachycardia, or fibrillation
.
Therefore, close ECG monitoring, especially in patients with pre-existing heart conditions, is important
for early detection and management.
▌ Other acute systemic complications
occur in 43% of patients, of which respiratory infections are the most common (71%-94%), followed by kidney infections (16%) and finally sepsis (7%-10%)
.
Early treatment reduces long-term hospitalization and progression
of RSE.
SE can endanger the life of patients, and the requirements for rescue time are very high, and clinicians should keep in mind its characteristics and diagnosis and treatment ideas to avoid delaying time
.
The focus is on stabilizing the patient's respiratory and circulatory state
Status epilepticus (SE) refers to frequent recurrences of consciousness that do not fully recover between successive seizures, or that seizures do not stop
on their own for more than 30 minutes.
Long-term seizures, if not treated in time, can lead to irreversible brain damage due to high fever, circulatory failure or neuronal excitotoxic damage, and the disability rate and mortality rate are very high, so neurologists should be familiar with the diagnosis and treatment
of SE.
The author summarizes the relevant content for your reference
.
Definition of SE SE has been defined as continuous seizure activity lasting more than 30 minutes, or intermittent but repetitive seizure activity lasting more than 30 minutes without regaining
consciousness between seizures.
However, given that solitary seizures rarely last longer than 5 minutes, the definition of SE has been revised
.
SE is now defined as a continuous seizure of more than 5 minutes or two or more discrete seizures during which consciousness is not fully restored
.
In 2015, the International League Against Epilepsy (ILAE) revised the classification
of SE based on seizure symptomatology, etiology, age, and EEG.
In clinical practice, the most commonly used classification is based on seizure symptomatology, which refers to the initial clinical manifestations
of seizure activity.
The two main components of initial presentation are the presence or absence of motor symptoms and the degree of
impaired consciousness.
According to the new classification in 2017, SE is divided into SE with obvious motor symptoms and impaired consciousness [i.
e.
, convulsive SE (CSE)] and SE without obvious motor symptoms, with or without impaired consciousness (i.
e.
, NCSE).
Diagnostic evaluation of SE The diagnostic evaluation of SE should be guided
by clinical presentation.
Common initial investigations include routine laboratory tests, drug toxicology screening, and CSF analysis
in patients with suspected infection or autoimmune causes.
In the acute phase, brain imaging (with or without contrast) by CT is the preferred mode to rule out causes of acute symptoms, such as intracerebral hemorrhage or tumors.
Once the patient is stable, further evaluation
is required.
MRI imaging of SE may resemble stroke, with abnormally high T2 signal and limited diffusion, often involving the cerebral cortex and hippocampus
.
CSE evolves into nonconvulsive seizures (NCS) and NCSE is very common, especially in the first 24 hours
.
Therefore, serial EEG monitoring should be initiated immediately, especially in patients with
persistent altered mental status and a high risk of seizure recurrence.
In critically ill patients with suspected NCS or NCSE, the use of ambulatory EEG can effectively improve the early detection rate of NCS/NCSE and reduce in-hospital mortality
.
The differential diagnosis of partial epileptic state of SE needs to be distinguished from transient ischemic seizure (TIA), TIA can appear episodic hemibody numbness, weakness, etc.
, without consciousness impairment, lasting for several minutes to tens of minutes, easy to be confused with simple partial status seizure
。
TIA is more common in middle-aged and elderly people, often accompanied by hypertension, cerebral arteriosclerosis and other stroke risk factors; Epileptic status should be distinguished from hysteria, migraine, hypoglycemia, and organic encephalopathy, and history and EEG are important differentiators
.
The processing of SE The treatment of SE mainly follows the following 4 principles:
(1) hemodynamic stability;
(2) rapid identification and termination of seizure activity;
(3) identify and treat potential causes;
(4) Prevent recurrence
of epilepsy.
Since most SEs usually occur pre-hospital, as with any medical emergency, it focuses on stabilizing the patient's respiratory and circulatory state
.
This includes keeping the airway open and intubating the airway if there is concern about damage to the airway
.
For patients with reduced oxygen saturation who do not require intubation, oxygen can be given through a nasal cannula or mask, and intravenous access is established
.
In addition, a rapid neurologic evaluation is required to determine the type of SE and underlying cause.
▌ First-line benzodiazepines
are recommended first-line ASM treatments
for CSE and NCSE.
The Neurocritical Care Society and the American Epilepsy Society recommend rapid administration of benzodiazepines within 5 minutes and 5-20 minutes
, respectively.
When intravenous access is available, intravenous lorazepam is the initial agent
of choice.
Lorazepam is administered at a dose of 0.
1 mg/kg, with a maximum rate of 2 mg/min, or a fixed dose of 4 mg, and can be repeated every 3 to 5 minutes if seizures persist
.
When intravenous access cannot be established, midazolam 10 mg intramuscularly is also effective and safe
.
▌ About one-third of patients with second-line
SE do not respond to benzodiazepine therapy, and the risk of seizure recurrence is high
.
Second-line long-acting therapy is essential to prevent seizure recurrence and to treat seizures that may persist, particularly in patients
at high risk of NCSE with persistent mental status changes.
Second-line antiepileptic drugs (ASMs) should be given
intravenously as soon as possible.
Levetiracetam, valproate, fosphenytoin, and lacosamide are the most commonly used drugs
.
Treatment of refractory SE is defined as ineffective
seizure control after adequate doses of first- and second-line ASM.
One third of patients with SE may progress to RSE and respond less than 10%
to the addition of a third ASM agent.
Rapid initiation of intravenous anesthetic drugs (intravenous access) is recommended to shorten the duration of seizure activity and prevent progression to super-refractory SE (SPSE).
These should always be initiated with ambulatory EEG monitoring to begin monitoring response, along with ongoing blood pressure monitoring
.
Complications associated with SE Convulsive SE may cause a wide range of acute and chronic systemic complications
.
▌ Neurological complications
Acute postictal encephalopathy is a common early complication caused by a combination of prolonged seizures and the use of sedative drugs
.
Focal neurologic deficit is another complication, particularly in patients with
focal motor seizures.
This may be due
to focal neuronal necrosis of the neocortex, hippocampus, and basal ganglia due to seizure activity.
Postictal weakness due to seizure activity is usually transient and improves
within minutes to hours.
▌ One third of SE patients with respiratory complications
will have airway damage and respiratory failure
that require intubation.
Changes in respiratory muscle contraction and the use of sedative ASM can lead to airway damage and, in severe cases, respiratory failure
.
However, sustained seizure activity is associated
with a higher risk of intubation compared with ASM alone.
▌ Cardiovascular complications occur in 2/3 of SE patients with cardiovascular complications
, which are associated
with increased mortality.
Electrocardiogram (ECG) changes are most common and can last up to 24 hours
after seizure activity stops.
At initial presentation, more than 80% of patients present with sinus tachycardia, and bradycardia
is rarely present.
Some patients may present with more severe arrhythmias, including atrial fibrillation or flutter, ventricular tachycardia, or fibrillation
.
Therefore, close ECG monitoring, especially in patients with pre-existing heart conditions, is important
for early detection and management.
▌ Other acute systemic complications
occur in 43% of patients, of which respiratory infections are the most common (71%-94%), followed by kidney infections (16%) and finally sepsis (7%-10%)
.
Early treatment reduces long-term hospitalization and progression
of RSE.
SE can endanger the life of patients, and the requirements for rescue time are very high, and clinicians should keep in mind its characteristics and diagnosis and treatment ideas to avoid delaying time
.
References:
[1] Wang Xuefeng.
New advances in epilepsy research.
Chinese Journal of Modern Neurological Diseases.
2022,22(07).
[2] TIAN Cong,LI Xiu'e.
Clinical research progress in drug treatment of status epilepticus.
Inner Mongolia Medical Journal.
2022,54(06).
[3] LU Lu,LI Jinmei,ZHOU Dong.
Status epilepticus progression.
Journal of Epilepsy.
2019,5(04).
